Arthroscopic Surgery of the Knee: History and State of the Art
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Arthroscopic surgery of the knee: History and state of the art CONRAD T. FRAIDER, DD. Philadelphia, Pennsylvania Consequently, the arthroscope followed. Even In the orthopedic management of knee today, developments in arthroscopes always have disorders, arthroscopy not only has followed developments in cystoscopes. become useful in diagnosis but also in Modern endoscopy had its start in 1805 when surgery due to technologic Bozzini devised the Lichtleiter, or light conductor, refinements in the arthroscope and for examination of the bladder. This was a crude accessory instruments combined with instrument by current standards, using a candle the expanding expertise of the for the light source. The Lichtleiter was a arthroscopist. The endoscopic origin speculum-type instrument, with a split tube, one and evolution of arthroscopy are half for viewing and one half for reflected light. 2 reviewed, as well as specific There were other investigators over the next 70 applications of arthroscopic surgical years who devised variations of the Lichtleiter and procedures and equipment for loose showed the usefulness of endoscopes in medicine. bodies, bands and adhesions, All of these scopes used reflected light. In 1876, osteochondritis dessicans, Nitze devised an instrument that had a platinum chondroplasty, lateral retinacular loop encased in a goose quill. This device also used release, meniscoresis, meniscectomy, reflected light but allowed a somewhat better than and synovectomy. The advantages previously obtained view of the bladder. Nitze was and disadvantages of arthroscopic obviously unhappy with this type of illumination, surgery are pointed out to show its because his records indicated that for optimal view- superiority over arthrotomy. ing the light source had to be at the distal tip. At this time Edison was still working on the develop- ment of the incandescent bulb. After its develop- ment, it took until 1883 to miniaturize it to fit the diameter of the endoscope. With technology finally Arthroscopy has become an integral part of the able to meet his needs, Nitze went on to develop the orthopedic management of knee disorders. It took first true endoscope,which had a prism to reflect many years from its introduction in the early 1960s light 90 degrees and a lens system that provided a to become a proven diagnostic tool. Until recently, limited amount of light transmission. diagnosis, therapeutic irrigation, occasional biop- In the next 30 years, Nitze and other investiga- sy, and removal of loose bodies have been the limits tors devised crude arthroscopes and reported on of the arthroscopist. The past 3 to 4 years have seen their findings. Takagi made the next significant the emergence of operative procedures performed contribution in 1918; he is credited with the first under arthroscopic control, due to ingenuity as true investigation into arthroscopy." He inspected well as the increasing skill and confidence of the cadaveric knees by using a 7.3 mm. cystoscope. arthroscopist. Also, the operating arthroscope with This scope was impractical for routine clinical use, an array of accessory and motorized instruments but by 1931, Takagi produced a scope with a 3.5 mm. has become available. To understand how arthro- diameter for viewing a knee distended by fluid.2 scopic surgery developed and how it is used at In 1921, Bircher published the first article on the present, this paper reviews the history of endo- arthroscopy of knees distended with carbon dioxide scopy and explains the basic arthroscope and ar- and dioxide. In 1925, Kreuscher described the use throscopic surgical procedures. of arthroscopy in the diagnosis of knee disorders, in particular, meniscal injuries.413 History of endoscopy If arthroscopic surgery is defined as any proce- The word "endoscopy" comes from the Greek word dure performed through the arthroscope, as op- "endo," meaning "within" and "skopein," meaning posed to that performed under direct arthroscopic "to examine." As mans knowledge of medicine and control, then credit for its development goes to disease increased, it seemed only natural that he Burman. In the years 1931-35, he developed his would have wanted to examine the inside of body own arthroscope as well as instruments for surgical cavities. It is from these desires that the first crude procedures. During this time he conducted exam- endoscope was developed, which was a cystoscope. inations of the hip, knee, ankle, shoulder, elbow, Arthroecopic surgery of the knee 817/81 and wrist, and reported on his experiences.2 able. They vary in diameter from 1.7 mm. to 6.5 The "dawn of modern arthroscopy" occurred in mm. and have different angles of view. The direct- 1960 with the development of the No. 21 arthro- viewing arthroscope has a viewing range of 10 scope by Watanabe, a student of Takagi. Watanabe degrees, that is, from 170 to 180 degrees. The went on to do the first partial meniscectomy under foreoblique arthroscope, which is frequently used, arthroscopic control in 1962. From this point on has a viewing range of 30 degrees, from 135 to 165 there have been contributions by numerous other degrees. The right-angle arthroscope only has a 20 investigators: Carson, Jackson, Johnson, Joyce, degree viewing range, from 90 to 110 degrees. With McGinty, and OConnor. From their continued ef- the use of these accessory viewing angles, as well forts the arthroscope became a valid tool of the as the smaller diameters, the arthroscopist can orthopedic surgeon. visualize difficult or remote areas of a joint without making a second entry wound. The smaller diame- The arthroscope ter needle scopes allow examination of the smaller The modern arthroscope has three fundamental joints of the body. In 1976, arthroscopy was ad- parts: the mechanical system, illumination system, vanced one further step with the introduction of and optical system. Each of these systems has been the operating arthroscope. This arthroscope had an upgraded over the years, as the technology has offset eyepiece that allowed the introduction of become available, to meet the requirements of instruments under direct arthroscopic control. modern arthroscopy, that is, adequate illumina- tion, sufficient angle of view, and durability. Arthroscopic surgery The mechanical system is essentially the in- Since its introduction, arthroscopy has grown to struments rigid housing or sheath, of various become an accepted diagnostic adjunct for the or- shapes and diameters. These were originally con- thopedic surgeon. As the skill of the arthroscopist structed of brass or nickle-silver covered by nickle increased, so did his diagnostic ability. In 1971, with a smooth surface. Currently, they are stain- diagnostic arthroscopy was about 80 percent accu- less steel. The illumination system started with rate; by 1975, it was 98 percent.° Arthroscopy reflected light, advanced to the incandescent bulb, also has shown superiority over arthrography in and now is fiberoptic. Development of fiberoptics diagnosing injuries to the menisci and anterior started in 1950, but industry could not produce cruciate ligament." By combining the diagnostic fiberoptic bundles of significant quality and at a modalities of clinical examination, arthrography, reasonable cost until 1958. The development of and arthroscopy, the diagnosis of knee injuries fiberoptic bundles made the incandescent bulb ob- should be 100 percent accurate. Diagnostic ar- solete. Currently, there are three optical systems throscopy has reached the point where it can be in use: objective lens system, rod-lens system, and done on an outpatient basis, using local anes- GRIN lens system. The objective lens system thesia. 11, 12 Thus, the arthroscopist naturally would utilizes a series of lenses with large air spaces want to effect treatment through the arthroscope. which transmits the image to the eyepiece. With Prior to undertaking any arthroscopic surgery, the advent of applying computer technology to op- the orthopedic surgeon has to be an experienced tics, the rod-lens system was developed. This arthroscopist. The surgeon should have the experi- utilizes thicker lenses with smaller air spaces, re- ence of performing several hundred diagnostic sulting in a more efficient optical system. The third arthroscopies. 8, ° He must be familiar with the lens system, the GRIN system, uses a single glass many portals through which the arthroscope as well component and is found in needle scopes. 1° as accessory instruments may be introduced.0,16 The Watanabe No. 21 arthroscope was the first These portals are most commonly anterolateral, arthroscope in the United States that gained any anteromedial, posterolateral, posteromedial, lat- preference. It was a telescope that utilized an elec- eral suprapatellar, medial suprapatellar, and cen- tric light carrier sheath measuring 6.5 mm. in di- tral patellar tendon splitting. The use of a probe in ameter. The tungsten bulb provided sufficient light diagnostic arthroscopy is advocated for the palpa- for examination as well as for color photography, tion of intraarticular structures and for develop- but this was also its major disadvantage. The bulbs ment of a stereotactic sense.° 5 '6 Finally, the emitted heat and required constant cooling. A large arthroscopist must have the instruments and be inventory of bulbs had to be maintained. The familiar with them. possibility of breakage during the procedure was In the early 1970s, there were only a few surgical always present. Due to these factors, most arthro- instruments, which consisted of biopsy forceps and scopes utilized a fiberoptic illumination system by scissors. Currently, there are 3, 4, and 5 mm. the mid-1970s. This gave the advantages of a cooler surgical instruments, including various knives, instrument, a remote light source out of the surgi- scissors, grasping forceps, probes, cutting forceps, cal field, and, most important, less fragility and baskets, instruments with retractable blades, and subsequent breakage. rongeurs.8, li" 15 There are also ribbed Teflon sleeves There are many types of arthroscopes now avail- for use in polypuncture technique to reduce trauma 818/82 August 1981/Journal of AOA/vol.